Pretty sure dealing with insurance not supposed to make you sick

Sorry you are dealing with insurance headaches - it is indeed difficult when already feeling vulnerable and stressed from treatment. Do you feel like sharing the specifics of the problem? some with direct similar experience may be able to help. Many of us had denials during treatment and can advise.

mameme - do you also have a specific denial you need to address?  It can often be issue specific.

Ask for the provider who is willing to do the treatment you desire to do a peer to peer review with your insurance company. He/she can discuss the merits of this treatment with whoever is the approving contact. If you are asking for treatment that is outside the standard of care for most insurance companies, it would not be unusual for it to be denied. I had one diagnostic test denied because my insurance company felt it was "experimental" even though it was FDA approved, but was able to get an out of network doc (plastic surgeon) even though there are in-network docs who do similar procedures, because he was the physician my surgeon preferred for the type of surgery I did have.

Mama - I have no idea, but it does sometimes seem that their jobs are to make things as difficult as possible. But I do believe a second opinion should be covered by most insurance companies, especially since you have had a significant change in your diagnosis recently.
What did they say their reason for denial was?

And, I am so sorry you have to deal with this

11/21/14

What should I do if the insurance company won't pay for the breast MRI (which your doctor ordered)?

1. Doctor ordered Breast MRI (for both breasts)

2. I told nurse at doctor's office that I don't want the procedure unless I know it will be taken care of by my insurance company.

3. Response from doctor's office: Procedure will be covered as long as the insurance company received a letter of medical necessity. The doctor's office submitted said letter to the insurance company.

4. I had breast MRI

5. Breast MRI was denied and I am stuck with a bill for $5,635

6. I contact doctor's office and they submit a letter of appeal

7. Insurance company denies doctor's appeal

8. Insurance company requests copy of all of my medical records

9. Doctor submitted my medical records

10. Insurance company still denied payment

11. I filed a complaint with the Illinois Insurance Board. They determined they couldn't be involved in the case or assist me in any way since the insurance company was based in Ohio

12. Illinois Insurance Board submitted my case to the insurance board in Ohio.

13. Reply of Insurance board in Ohio was a copy of the original denial letter from the insurance company

All the while these steps were taking place, I continued to contact my doctor's office for their help. This was continually put back as my responsibility to take care of. I also was in contact with the billing department at the hospital where the breast MRI was done. Although a doctor in their hospital issued the diagnostic procedure and they told me it would be approved, the billing department staff kept telling me it was my responsibility to pay the bill. Yes, they offered a discount only if I would pay $3,000 in full. I was and am still not in a position to pay that amount at once. Even though I had been in communication with the hospital's billing department, the insurance company, and the doctor's office, my account was sent to collections. So that my credit rating wouldn't be gravely affected by this, I continued to pay monthly payments.

In the past several months, I have told people I know about this situation. Everyone I have talked to (including medical personnel) about this in recent months have indicated that I should not have to pay for the breast MRI. I agree.

Talking about this issue again has given me new courage to fight for a refund for what I have paid so far and for the hospital to zero out the balance of the remaining amount on the bill.

I have since contacted my doctor's office and spoke to a nurse who wasn't working at the doctor's office at the time of when I had the breast MRI. I have written one letter to the doctor's office, the hospital billing department, and the collection agency. She agrees that I should have to pay for the procedure and has agreed to review the letter. I am grateful for that. I also asked her to reassess the codes that were used for the diagnostic procedure and that it may make sense for the doctor to have a peer-to-peer review (again) with a doctor at the insurance company.

However, I am hoping I don't get lost in a perpetual loop of phone calls and finger pointing like what happened before.

I am realistically optimistic that I will get my money back.

I am writing here to share my experience and to ask if anyone else has had any success with getting their insurance company to pay.

Thank you for listening.

Wow Julio that's quite a story. I had an almost similar situation last year and included a few details in a thread here called "Use Your State Insurance Commissioner's Department" (scroll down for it). Sounds like you tried and got very little help. I am truly sorry about that.

I was able to file an appeal and go in person before a committee that included a lawyer & doctor as well as someone on the phone. I had a copy of the applicable policy and several journal articles supporting my case. Do not be intimidated by their bureaucracy. The only way these companies make money is by not covering claims. They love to deny benefits but it is possible to win.

You are keeping good records and documenting all contacts. Get names and write down dates/times of calls. You may have a typo in the paragraph about the new nurse: hopefully she agrees you should NOT have to pay. Do you know how to edit a post in order to correct it?

Hi JulioAnn,

So sorry you are dealing with such issues with getting MRI covered.

I am not asking or suggesting you put anything public you are not comfortable doing, but...

A big part of your situation is why was the B/L MRI done?

If you have a diagnosis of breast cancer via another study, then it may make a difference and make this easier for you.

What is the exact reason they are denying the MRI?

If you have the exact procedure code and exact diagnosis code, then see if you can find on the insurance web site some written material on their coverage for those codes.

bumping for hopeful 82014 - specialk always has good advice. If she doesn't see your post, you could send her a private message